Office Policies



Thank you for choosing Elk Grove Dermatology, S.C. as your healthcare provider. We are committed to your treatment being successful. Your clear understanding of our financial policies is important to our professional relationship.

We make every effort to decrease the cost of your medical care. Our office accepts Medicare Assignment, Blue Cross Blue Shield PPO, Blue Choice PPO, Ascension Smart Health and United Healthcare PPO.  If you have insurance other than the plans listed we require that you pay for your visit at the time of service. We can provide you all the information you need to submit the claim to your insurance company for reimbursement if you choose to do so. Co-payments are collected at the completion of your visit and estimates are provided at the patient's request for further services that may be recommended. 

We strive to work with patients with balances that may remain after the insurance has processed charges. If you fail to make monthly payments on a balance, your account will be forwarded to collections after two statements have been generated.  

Medical Records 

Patients can request their medical records at any time. Please print out the form below, fill it out completely and mail it to the office. If you would like to bring the completed form to the office to get your records in person please call ahead so we can have the copies available for you upon arrival. Thank you. 

Medical Records Release Form


With the exception of emergencies, it is expected that you keep all of your appointments. If you need to reschedule an appointment we require 24 hours notice. Please contact our office to reschedule or messages can be left with the answering service is a cancellation needs to be made after hours.  

24 Hours notice is requested when canceling or rescheduling your appointment to avoid a fee:

Medical Office Visits will be a $20.00 charge

Cosmetic visits will be a $40.00 charge

Surgery appointments will be a $50.00 charge

Medical Emergencies

We provide 24-hour emergency coverage for all patients. If you have an emergency after office hours, call our office at 847-593-6222. The answering service will take your message and contact the covering provider immediately.

Patient Forms

Elk Grove Dermatology, S.C. provides our patients with office forms for your convenience. We recommend you print and fill these forms prior to your appointment to save time. Forms 1-3 are for you to print and fill out, Forms 4 & 5 are for you to print, read over, and bring with your other paperwork. 

#1 Medication List

#2 Medical History Form

#3 Patient Registration Form

#4 Patient Financial Policy

#5 Summary of Privacy Practices

For Self-Pay Patients, Please Print and Fill Out: Self-Pay Patient Financial Policy

Note: These files are in PDF format. If you do not have AdobeĀ® ReaderĀ® on your computer, you can download it for free by clicking here.